CHAPTER 3
Affirming people as unique individuals
It is when we really look at people, really see them, rather than making assumptions about them according to the category we have placed them in, that we respond to them as human beings and accept them with understanding.
Identity is almost synonymous with spirituality, so it is when our identity is respected that our well-being flourishes. Perhaps the most essential aspect of helping people to make the transition from living in their own homes to settling into residential care or nursing care accommodation is to take the trouble to notice the character of the individual, to respond to that with affirmation, and to help create contexts and strategies that will protect and celebrate that sense of personal identity.
Since 1986 I have owned a wonderful Time-Life Library of Nations book about India. My favourite part in it is a short photo-essay entitled “Daily Life of a Calcutta Clerk”, detailing the everyday routine of Sukumar Chowdhary and his family. He is described as living “with his wife, two grown-up sons, his aged mother and a maidservant in a brick house which his father built in an outlying suburb of Calcutta”. The pictures (by Pablo Bartholomew) show him travelling to work, at his office desk, in the market buying betel leaves to make pan, returning in a rickshaw from market with his son Subir after purchasing the groceries for the day, and eating with his sons and his wife as their maidservant looks on.
The maidservant is also shown cleaning the family bathroom. Sukumar’s wife Bidyut is shown cooking supper, and her sons, Subir and Sudip, are shown dismantling the mosquito netting from their beds as part of their morning routine.
Near the beginning of the essay is included a picture of the whole family, captioned:
Sukumar and his wife Bidyut pose with their sons, 22-year-old Subir and 21-year-old Sudip (wearing glasses). Both young men have high educational goals: the elder is working for a civil engineering diploma, the younger for a degree in commerce. They will not marry until they have secure jobs.
And, sure enough, there they are, dignified, slightly smiling, standing straight and proud: Sukumar, with his pen in the breast pocket of his white shirt, at the front in the middle; Bidyut, in a clean pink-and-white sari, to his right and just slightly behind him; Subir and Sudip, side by side behind their parents. Behind Sukumar and Sudip, you can see the turquoise-washed exterior wall of their home, and the door frame painted in vibrant, rich, dark green. Behind Bidyut and Subir can be seen the open doorway to the cool, deeply shadowed interior.
In the more than twenty years I have owned this book, I have returned to it often to look at this photo essay. I have been inspired and encouraged to see the dignity and simplicity of this Calcutta family and their way of life. I like to look at them standing in a row, looking out at me, smiling gently, showing me from far away across the world how life should be lived.
But one day, I was looking at this lovely photograph and something caught my eye. “Wait a minute!” I looked closer. Sukumar, Bidyut, Subir, Sudip… so… who is this?
I realized that within the darkness of the doorway, standing back a little behind Subir’s right shoulder (possibly reflecting her place in the authority structure of the family, like Bidyut standing a little behind her husband?), is another figure, standing in the family group. Even in the deep shadows within the doorway, you can make out not her face, but the folds of her clean white sari. A widow would wear a white sari.
Who was this mysterious figure in the doorway? I did not think it would be the family servant, because this is intended as a formal family photograph, and she does not even sit down to eat with them. I imagined it must be Sukumar’s “aged mother”, Mrs Chowdhary, the one member of the family who is given no name and appears in no photographs except, perhaps, this one.
I wonder what Mrs Chowdhary felt about that?
I wonder how it felt for this family – hard-working, intelligent, able people; successful by middle-class professional Calcutta standards, but living in such material simplicity by Western standards – to be told they were to feature in a book published in America, a study of India, and their home would be there for all to see in the Time-Life Library of Nations? My guess is that they felt immensely proud and that they may have obtained a copy of this book and kept it as a family heirloom – just as you or I would have done.
And when the long-awaited book was finally published, and a copy came to them and they opened it to admire the pictures of their home and family life, I wonder what the nameless Mrs Chowdhary senior felt about the manner of her inclusion?
I had that book for years and returned to it again and again to study this short photo essay (which fascinated me) before I even noticed a fifth person in that family photograph. You can tell that the photographer hadn’t noticed either, or she would have been mentioned in the caption. She was there but not there. And yet it was her home: the brick house that her husband, now dead, had built for her and him to live in together, the place where they had raised little Sukumar with tenderness and pride, and watched him grow into a man, responsible and successful.
I can imagine being Mrs Chowdhary, searching through the book with the rest of the family, and then feeling the intense disappointment when she had been reduced to nothing but a shadow in the only picture that included her. I can even imagine that the rest of the family may have found it amusing, and she would have had to hide her disappointment and present it as a great joke.
I wonder, too, how the photographer felt, and the publisher, about this inadvertent exclusion. I don’t suppose they would be callous people, indifferent to the sense of hurt and disappointment that others might feel. My guess is that they simply didn’t notice Mrs Chowdhary’s presence, and absence, in the photograph. She was only an old lady, incidental to the core story
I wish I had a way to reach back to the time that photograph was taken and set this right: to give Mrs Chowdhary senior a face, a presence, a position – to restore to her the place in her own life that was rightfully her own. Nobody should be allowed, by careless oversight, to be excluded from their own life.
The individual and the system
It is very important to the staff of a care home to facilitate ways for the residents to flourish as individuals, continuing to feel affirmed as people. Especially if the nursing home or residential care home is a large one, imagination is needed to help each resident feel that they are known and considered. Nobody should ever feel like a cog in a big machine, lost in an impersonal institutional system.
When I moved from my employment as chaplain at a Methodist school to take up a new ministerial appointment, the time came for me to apply for a place for my youngest child to attend the state school local to our family’s new home. Her three older sisters had secured places there and were happy. There was, however, fierce competition for places in the appropriate year for my youngest daughter. We went through an appeal procedure without success, and she stayed on as a weekly boarder at the Methodist school. In the many meetings I attended as we went through this process, I was struck by a significant difference between the two schools. In the state school (it was a very good school, and those of my children who attended had a positive experience there), the emphasis in every meeting to discuss outcomes was the well-being of the school. In the Methodist school, the emphasis throughout was on the well-being of the child. Although both schools were excellent, I felt that this significant difference in emphasis made the Methodist school’s approach more conducive to the flourishing of the individual. Having said that, my second daughter felt immediately at home in the state school, whereas she had loathed the experience of education in the Methodist school.
From this I draw two lessons: first, that no one system will suit every individual, so care homes with a variety of approaches will always be helpful; and, second, that it is necessary to discern, when exploring the possibility of residency, whether the emphasis will be centred more on the well-being of the individual or on the smooth running of the community as a whole. Both aspects will be present in the care provision, but there will be this difference in emphasis. Although places that emphasize efficiency and organization will often provide excellent care, I believe it to be generally true that the chances of remaining visible as a person are much greater where the well-being of the individual is valued above the well-being of the system.
When somebody goes into residential care, they are entering a system. It will not feel quite the same as being in one’s own home. There will be a system for the catering; there will be a system observed by the nursing staff to ensure that the care and medication of all the residents are well and efficiently covered; there will be a system for laundry, and name-tags on clothes will be necessary and maybe on other personal belongings as well. A friend once observed to me that, in order to get anything running smoothly, “You have to have a system”; again and again I have remembered his remark and found it to be true.
In a community of people, especially one in which the residents are vulnerable, needing support in everyday life, everything would very quickly go wrong without a system.
But people can better accept the self-discipline and compromises necessary to taking their place in community when they feel individually heard and beheld.
This doesn’t add to the burden of the care staff and volunteers; it is more a matter of emphasis and approach than of adding in something extra. Most people who work in residential care homes and nursing homes have a warm and genuine interest in people and enjoy getting to know the residents as individuals, taking a pride in getting the details right for them in providing their care.
If someone new joins the care staff team, they may be told that “Bill always likes a packet of crisps with his cocoa” or “Ernie always likes a big cup”. It is always the individual details that staff get to know. And they will tell the new staff member about the client’s personality, or if the client is feeling tearful because of some recent sadness or upset. Even though the care staff will inevitably be kept busy, they spend time helping clients with personal care, and residents will share all kinds of things during these times. The members of the care staff come to know all sorts of personal things about the clients, understanding their preferences and their outlook on life.
Residents also enjoy as much choice in their daily life as is reasonable and possible in a communal setting. The care team works to make life as interesting and enjoyable as possible, but even if they were not inclined to do so, client choice is strongly emphasized in modern care home policy.
For example, residents can expect to be asked the day before to choose from a menu of three different meals, and they also choose what drink they have for supper.
Some years ago I was intrigued and impressed by the findings of a survey into urinary incontinence among people in residential care homes for older people. The residents were (unknown to them) divided into two groups. One group was offered choices in the matter of their daily care: when an outing was proposed, they were given a choice between two possible places to visit; when everyone was given a pot plant, they were allowed to express a preference for a pink or a blue plant. The residents in other group were still taken on an outing, still given a plant, but they were never given a choice. Among the group offered the opportunity of choice, a significant improvement in urinary continence was noted. Not only is this demonstrating (if demonstration were needed) that self-expression is vital for basic health, it also means that taking the trouble to allow individuals to have a say in what happens to them will also cut down the expenditure on incontinence pads, gloves, washing, disposal bags. And it must surely be preferable for a care assistant to spend a little more time relating with a resident’s thoughts and feelings and a little less mopping up their accidents.
Another initiative I heard of, from the same enlightened continence advisor who came to address us, was the introduction of a poetry group in a residential community where there was very little for people to do together. Those who joined in with the group – listening to poetry, writing poetry, getting involved in discussion – enjoyed a marked improvement in urinary continence.
Feeling loved
The care of an individual is more than physical and medical. Clinical excellence is more than measurement and calibration and the provision of the right surgical appliances. As we know from famous experiments with which every clinician is familiar, babies die when they are not touched and talked to – when they are not loved. Nothing changes when we grow up. Of course it is necessary for our medication to be double-checked. Of course it is necessary for a supra-pubic catheter to be flushed out, or blood sugars to be monitored, dentures to be scrubbed, urine bottles to be sterilized, plastic gloves to be donned in giving personal care – but it is just as important for residents to know, to feel, to see, that they are loved.
Back in the 1970s, in his book Spare The Child,3 W. David Wills discussed the insight that every culture contains a subculture, and that the members of the subculture will always faithfully mirror the attitudes of the members of the dominant culture.
I found this concept immensely helpful when I was raising my children, because it meant that if I saw anything to criticize in the behaviour of my children, the most effective way to change things was not by rebuke or instruction, but by correcting the behaviour (hitherto undetected!) in myself. It worked every time without fail.
If the parents are dishonest, the children will be too. If the parents harbour attitudes of contempt towards others, so will their children. If the parents forget courtesy, the children will follow suit.
This applies in any culture – the subculture of the pupils will reflect the dominant culture of the staff in a school, for example.
In Spare The Child, David Wills was writing about unhelpful, dysfunctional cultures, in which the subculture becomes a frightening parody of the regime intended by the dominant culture – yet very revealing of its reality. Wills wrote about the coming of a new headmaster, Richard Balbernie, to an approved school for delinquent boys, in Britain in 1967. The new head had been appointed to deal with a culture of violence and bullying among the boys, which had proved too tough to root out.
When the new head arrived, instead of instigating a harsh and punitive regime to combat the callous and dangerous behaviour, he set to work establishing a new culture of respect, in which all people could be heard and beheld, and in which there was room for gentleness. I was especially intrigued by a new practice Balbernie put in place in one special unit within the school. Every evening, through the cold winter season, the members of staff were to place in each boy’s bed a hot water bottle.
The point of this was that it served no purpose except kindness. It demonstrated care and concern for the well-being of the boys, and could not be interpreted as having any other motive. The new head turned that school around.
What he did was harness the psychological imperative that the subculture will faithfully mirror the dominant culture. As the staff began to show thoughtful, gentle, imaginative kindness, so did the boys.
Residential care homes also have dominant cultures and subcultures; and the prevailing sense of well-being among the residents can be greatly enhanced by addressing the sense of well-being among the staff. This can be especially noticeable when working with people with learning disabilities. If the staff are out of sorts, it affects the residents negatively, and if the staff are happy and harmonious, it affects them positively. They sense the mood and are dependent on it.
Spiritual care
I worked in a large nursing home offering palliative care to dying people and long-term care for people with chronic conditions, where a visionary matron introduced a programme of spiritual care training for her care staff.
This nursing home was linked with a hospice, into which funds poured from the local community and where the highest standards were always observed. The care staff of the nursing home saw their community as a much lowlier outfit. There was less money available, fewer appliances, a less sophisticated in-service training programme – and there were fewer nurses and more care assistants. They felt very insignificant in comparison with the beautiful place next door.
When the matron began her education programme and included the spiritual care module, it was regarded with a certain amount of bewilderment and suspicion. The cultural background of many of her staff did not include attending discussion on the ways and work of the soul. “Moving and lifting?” – yes; “Insertion of catheters?” – certainly; “Preventing the spread of disease” – OK; but “The Spiritual Role of the Auxiliary Nurse?” – er…
As the programme continued and the personality of the matron made itself felt, the mood of the whole place changed. She believed in people. She valued people. She took the trouble to understand them; she gave them a chance. She thought the best of them and sought the best for them.
Her staff began to notice the effect of the way they spoke, the way they looked. They saw the value of taking time, of listening, of treating people as valued and special – because that was how she treated them.
That nursing home became a wonderful place to be. It was, in the fullest sense, redeemed.
In lifting the atmosphere of a residential care home to becoming a place where people blossom and flourish, there are no short cuts, and the starting point is valuing the staff and putting in place practices designed to make it clear that people are loved here – practices with no purpose other than to make life nicer. When I worked in a hospice, the meal trays were always made up with a tray cloth and a tiny individual vase with a nosegay of flowers. It was a “namaste” – a saluting of the patient’s immortal soul, precious beyond worth. It didn’t cost the earth, it didn’t take much time; it was simply an exercise of the imagination designed to spell out to each resident the reality that “You are worth something; you are special; you are beautiful.”
Being visible
Being visible is linked to expressing preferences. The phrase “making a difference” helps us to see that. If we make no difference, we often feel we might as well not be there. When we say someone “makes a difference”, we mean they matter.
It is hard to see how you matter when the smooth running of the system depends on all the residents making as little difference as possible. Change, in such circumstances, is related to problems, objections, and difficulties. Nobody changes the system just to express themselves – how annoying would that be! You have to fit in. Perhaps because of this, I have known those nursing home residents who liked to express themselves viewed with alarm and suspicion.
I remember Venetia, a lovely woman with a delightful smile; kind, alert, and positive. When we as care assistants came into her room, we were greeted with warmth and welcome, as if we were guests in her home. She enquired after our families and was interested in their doings and happenings; she told us about her family, her sons and their work, their lives.
You might have thought such a resident would be a popular member of the community, but, in fact, she made the care staff uneasy and was regarded with the deepest suspicion. I was warned about her: “Don’t let her manipulate you – she’s a very difficult woman.” I knew her until she died, and in all that time I waited for the manipulation to begin, but it never happened.
What did people object to? She liked to have her cranberry juice in a glass jug (not from the carton), mixed with water to the dilution she preferred, and with a straw because she had trouble swallowing. She liked to wear several rings, and when she was washed at bedtime, she liked to have them taken off so her hands could be washed thoroughly and have hand-cream applied. She liked to watch Newsnight and Question Time and preferred not to be disturbed for her bedtime ritual during those programmes (before or after was fine). She liked to be comfortable in bed – and since she was completely paralysed, this was not always easy to achieve; sometimes she had to ask the care staff to come back several times, always courteously, sweetly. When she was washed, she liked to have the door to her room closed, and to have her nakedness covered with a towel, for modesty, except for the part being washed.
I never knew her be rude or ill-tempered, never heard her express anger or resentment about her condition. She was totally immobile, unable even to read unless the book was carefully propped for her, incontinent, losing her ability to swallow, but I never once heard her complain. But she was “difficult” because of the glass jug, the straws, the rings, the modesty, the TV programmes, and calling us back because she was uncomfortable. Venetia paid several hundred pounds a week to live in that residential home; I don’t think she asked too much. She was “manipulative” because she made a difference; she saw herself primarily as a person. And – possibly even more threatening – she saw us as people too; she saw us as the same kind of thing as herself. Venetia did not expect that two care assistants washing or hoisting her would be chatting to each other over the top of her about their weekend date: she expected to be included in the conversation.
Losing the right to self-expression, choice, and individuality is, I think, what is usually most dreaded about making the transition into residential or nursing care.
This prioritizing of the system over the people is not usually because the staff members are unkind or themselves have an impersonal approach, but arises when there are not quite enough staff to get through all the work necessary to ensure that residents receive all the support they need. For this reason, it is more likely to be a challenge for nursing home staff than for residential care home staff. In a nursing home, it can take all the energy and time of the care assistants simply to see that everyone is clean and comfortable and fed, and it is important that everyone follows the routine closely to achieve that end. In a residential care home, although the clients need support, they are relatively able, and this gives more flexibility to the situation. The simple answer – employ more care assistants – would, of course, add considerably to the cost of the care package, which already presents a considerable challenge to some prospective residents.
Even in a busy nursing home, where it is unfair to destabilize the routine for no practical purpose other than personal preference, it is possible to find ways for residents to express the individuality of their own unique personalities.
The best care assistant I ever knew was Sean. I never saw him rush, but he got through a prodigious amount of work and could often make himself available to help out if staff were rushed on one of the other floors. Gentle and unflappable, he made everyone – both residents and colleagues – feel that they mattered to him. When he came into a client’s room to wash or dress them, he always smiled at them and greeted them, explained what he was going to do, and continued to chat to them quietly as he went about the care procedures. But I think what I loved best about Sean was the way he looked at people: properly, as if he was really seeing them, considering them, caring about them. Everyone loved working with him and everyone loved being looked after by him. Like all of us, he was under pressure to complete the care routines for a large number of people within a tight time frame, but he made it seem easy. He had no more time than the rest of us, but his attitude made all the difference. Sean liked people, and when he was there, they knew they were no longer invisible because when he looked at them, they knew he had really seen them.
When I worked as pastor to a congregation, I felt acutely aware of a sensitive moment in visiting members of my church when they were staying in hospital – the moment when you look along the ward with its facing rows of beds full of patients, all looking eerily similar in their pastel nightwear, and think, “Where is she?”
I soon learned to ask at the nurse station before entering the ward, identifying the position of the bed containing my church member, so that I could move confidently past the strangers, straight as an arrow to the bed of my friend, disguising from her the awkward reality that, in her nightie, at first glance she looked just like everybody else.
It was while I was part of a hospice chaplaincy team that I learned the value of shrewd choice of bedwear. I spent a substantial amount of time with one particular patient in the hospice in the last weeks of his life: a gay man with a very strong sense of identity fought for and tenaciously retained in the teeth of social prejudice, greater then than now. I never saw him (not even once, not even on the day he died) in pyjamas. He wore clothes. Very weak, very thin, dependent on care staff to wash him and help him to the bathroom, confused and tired, nonetheless he was clear in his option to remain, at all times and in all circumstances, a person, not a patient. In the warmth of the hospice rooms, he chose often to wear T-shirts and boxer shorts, as he might have done sitting out in the garden on a sunny day, but it was distinctly daywear.
This, I noticed, changed the way those who approached him behaved towards him. Our clothes are probably one of our strongest ways of allowing strangers to read our personalities and form an understanding of who this is in front of them. How we dress enables people to categorize us, fit us into their frame of reference, and feel they have met us.
Personal choices
Making a clear option for personal choice encourages others to respond to us not as units but as people, enhancing the sense of each encounter between patients and staff as being a meeting of people’s souls, not a category interface.
Three small, vivid experiences about personal choice have imprinted themselves unforgettably on my memory. The first was an experience recounted by a fellow student when I was an undergraduate in my early twenties. My friend had taken a summer holiday job as a hospital porter, and he was about his work on the ward one day when he overheard a conversation between an old, sick man and a nurse. The old man, who was in the last stage of his terminal illness, was asking for a banana; the nurse was explaining that he couldn’t have it because it contravened the requirements of his diet sheet. The next time my friend’s portering duties took him back to that ward, the old man was dead. He never got his banana. The nurse was right, of course – it would jeopardize her job and risk the health of patients to administer unsuitable foods. That’s why people dread going into institutions. If you’re dying tomorrow, the banana is more important than the rules; people know that, but institutions don’t. I took a funeral one time when the niece of the deceased spoke affectionately and imaginatively about her aunt. She recalled her many visits to her aunt’s home and how on arrival the aunt would always have a cup of tea and a ginger biscuit ready for her. The niece sketched for us the picture of the moment when, on her own death, she came to the pearly gates: there would be her aunt waiting for her, with a ginger biscuit and a cup of tea at the ready. Listening to her made a difference to how I have lived my life, because, in focusing on the story, I realized that although it was attractive and delightful, it wasn’t true. Whatever may happen to us when we die, of one thing we can be sure: there will be no more ginger biscuits and no more cups of tea. If you want them, have them now – life is fleet of foot, and it is passing, and however magnificent heaven and eternity may be, there are some things that belong only to this earth, this life, this humanity. Bananas come into that category.
The second of those vivid memories of significant details came from a terrifying and protracted relationship with a mentally unstable woman. She had young children at the same time as I did, and she was very violent towards them because of the extremity of her condition. Frightened to be alone with her, dreading her company, I was hardly able to see her as just another woman like me, until the day when she mentioned in conversation that she had chosen her house because it had a sea view, and the thing that mattered to her above all else was that she should be able to see the ocean that she loved from her home. Disconcerted, I reflected on what it meant to be so ill that you could punch and bite your toddler, lifting him up by his hair and beating him, but still really treasure and draw inspiration from your view of the sea from a bedroom window. It made me realize that every single one of us is a person, an individual; there is nobody who merely represents a category.
In the childhood room I shared with my sister, my bed was alongside the window. The white candlewick curtains had a pink lining, and outside in the garden grew a tall Scots pine where collared doves roosted among the branches. At sunrise, the room would fill gradually with pink light, and I would wake to the contented cooing of the doves. Reaching up to pull back the curtain, I would lie in bed and gaze at the birds sitting in the tree. I was entirely happy.
My bed in the house where I live today is also alongside the window, and when I wake in the morning I pull back the curtain to look out at a tall, graceful, golden conifer, flanked by deciduous trees. I watch as flocks of birds make their way across pale grey cloud, as the sun rises in pink and gold, as white drifts of cloud like pulled cotton wool float against an azure heaven. And I am entirely happy.
It has occurred to me that, having lived a very simple life, with not much to miss in the way of status, achievement, wealth, or possessions, though I should miss strength and independence very much, I could probably still find my way to contentment if you left me in a bed alongside a window where I could see the birds and the trees and the sky. If, on the other hand, you wheeled my bed into the midst of jolly human society, under fluorescent lights, with no tranquillity, no solitude, no peace, the windows giving on to the car park or the dustbin yard, my daily prayer would be for God to take me home.
My third memory of vivid detail concerned the last days of my granny, my father’s mother. Lying in her hospital bed, this stout, vigorous woman had now grown frail and very old. A member of the staff came to ask what she would choose for her tea. From among the options offered, she chose to have a boiled egg (a favourite teatime food for her). And she said, if it were possible, that she would prefer it to be soft-boiled. Again I was arrested by the consideration that, even in the momentous time of saying goodbye to this world and all it has meant to you, it still matters whether your egg is soft-or hard-boiled – possibly more so even than before. Something else about this that intrigued me is the effect it had on my mother, who was there when the conversation took place. My mother loathed this old lady with a passion – though she dutifully visited her in hospital and did what she could to take care of her – but when she heard this request, for a soft-boiled egg, she saw her mother-in-law differently – less of an archetype, more of a person – and thought more kindly of her. It was a window into the older woman’s point of view – almost a first realization that she even had a point of view and was not merely sent here to try the patience of her relatives. Could this mean, then, that to give infirm residents in nursing homes more choice, more opportunity to express themselves, might not render them more of a nuisance but less so? Not because they would be easier to look after, but because we would identify with them better as human beings and care about them more – even the ones we found obnoxious and difficult.
Forming a strategy
Because being recognized and understood as unique individuals contributes significantly to our well-being, it seems sensible to consider ways in which we can communicate something of our history and personality when we are newcomers settling into a communal setting.
When the arrangements are made for someone to make the move into a residential care home or nursing home, there will be many questions asked in advance of the actual move, to make sure that this is the right place for this particular person and to ensure that the right care can be provided.
The care needs of the new resident will have to be discussed: mobility, personal hygiene, ability to dress themselves, level of continence, whether the client is diabetic or has any other special needs. Such information will, of course, be even more detailed when the person requires nursing care as well as a residential place.
This detailed information will be discussed in advance of moving in. At this time it will also be possible to discuss what items the new resident can bring to make their room feel like home. This will vary considerably: my own experience has ranged from a nursing home setting where rooms were shared and there was space available only for a few personal possessions – photos and ornaments, perhaps, to be displayed on a chest of drawers – to a residential care setting where the rooms were unfurnished, allowing the clients to fit their rooms entirely with familiar and beloved items brought with them from their own homes.
When the day arrives for the new resident actually to move in, the manager on duty chats to them (and to any family members who have come too) and tries to get to know them a little, and then will usually send one of the care assistants to label the clothes. This is a time of chatting to the family and the client, getting to know them and helping them feel comfortable.
Of course, everything will feel unfamiliar at first, but gradually the resident and the care staff will come to know each other as individuals.
As time goes on, there may be a visit from a volunteer or a chaplaincy team member designated to that particular new resident to ensure that they are seen as a person; loveable, vivid, unique.
It should also be said that kindness and respect ought to characterize the attitude of the resident to the care staff, as well as of the care team to the resident. Rudeness and demanding behaviour in residents is not unknown, and although care staff will understand that people who suffer from confusion or dementia, or who are simply vulnerable and fearful, may behave badly, a culture of mutual courtesy and respect is always to be encouraged.
The role of family and friends
Family members clearly have a very important role to play in helping someone make the transition from living alone to residential care. Not only will they know this individual well, but they are likely to have many similar preferences and priorities, because these are very often common to all the family members. At the time of admission to residential care, the prospective resident may be too confused, unwell, or overwhelmed to state (or even identify) the things that matter on a daily basis. If the individual is an older person (and it is most likely they will be), their daily habits will not be newly forged, so it may even be difficult for them to recognize that they are exercising preferences and priorities in the first place – living alone, those things seem just like “how life is”.
I became very aware of this when I married at the end of my forties. When we went to the garden centre to buy containers for pot-plants, of course I wanted the nice old-fashioned terracotta ones, ignoring, as if they were not there, the vile, garish, bright-blue glazed pots. How disconcerted I felt when my beloved bypassed completely those dull, ugly, terracotta pots, making a beeline for the beautiful, elegant ones over there – the ones with the lovely blue glaze!
It was the same with tea and coffee. “What’s this?” I wondered in horror, gazing down at the tarry liquid filling the horrid little white chimney shaped mugs. It was my beloved, making me a delicious cup of tea, passing over those ill-matched, second-hand teacups in favour of a smarter vessel, to make it extra nice.
Same when we went shopping. “Could you pick up a cake to take over to my mother’s?” I would ask, never expecting him to return with a packet of some loathsome pastry and mincemeat concoctions, or something shiny and infested with figs, when what I’d imagined was a lemon drizzle cake or a fresh-cream fatless sponge.
And I just sat open-mouthed with horror when, having scraped the low-fat spread on to my toast, topping it with a translucent film of marmalade, he could have done with a plasterer’s trowel for his butter and poured the jam straight from the jar! I thought the bread was the main part; he regarded it as the support act for the jam and the butter.
What makes life comfortable, cheerful, enjoyable, especially as our opportunities and possibilities become restricted by growing old or ill, is the seamless tissue of everyday preferences. Do we like the bedclothes pulled right up to our chins, or does that make us feel we can’t breathe? Do we love to have the window open, or are draughts uncomfortably painful? Do we like our cereal soggy with hot milk, or do we find it almost too disgusting to eat if the milk isn’t cold and the cereal flakes still crispy? Does bright light hurt our eyes unbearably, or is “contentment” synonymous with “sunshine”?
These are the things our family members will know, but may not have the imagination to think of. A good induction process for a prospective resident would include time spent considering and discussing such preferences – with prompts and examples such as I have outlined here. Just asking “What does your father like?” is insufficient.
Even when these preferences have been communicated, it may not be easy for them immediately to become part of the pattern of daily care. Care staff often take a pride and pleasure in knowing the residents well and ensuring that they have what they need to be happy – especially when the residents are courteous and pleasant – but it takes a while to get to know the ways and idiosyncrasies of someone new. An induction process that includes creating a folder that care staff and nursing staff can refer to would encourage the process of becoming familiar with the preferences of this individual, and encourage the practice of respecting those preferences where possible.
In the early days of settling in, family members could do much good by keeping a benign eye on the progress of establishment, affirming appreciation and positive attitude, offering reassurance and a sense of continuity. It is important that the transition into residential care should be seen as marking not the cessation of family responsibility, but a new expression of it.
Family members may also be crucial in helping to select the right possessions to bring into this new context, to make it feel more like home. My friend Margery was a stained-glass artist and banner-maker, and a devout Christian believer. Her sense of identity was founded upon being an artist, a Christian, a mother, a teacher, and wife to her deceased husband. When she made the transition into care in the last year or so of her life, her son helped her to choose a stained glass panel and a banner from her collection of pieces she had made, to bring with her. These were hung ready in the room for her arrival, along with a number of other treasured possessions. Although the relinquishment of home and possessions caused her much distress, and although she was almost blind, it meant a great deal to her to have these statements of who she was and what her life had been so prominently displayed in her room.
A chaplaincy member could be very helpfully included in preparatory planning and discussions, prompting the direction of thinking with questions that need to be asked, and helping to explore the emotions that may be restless below the surface.
Friends and chaplaincy volunteers can also provide tremendous support. This is the fulcrum effect: a small action that creates a big result – just a ten-minute visit, perhaps to drop in a magazine or small posy of flowers or a beautiful piece of fruit, bringing a sense of contact with the outside world.
Handling the sense of loss
The intense bereavement of leaving one’s home for the last time cannot be overstated. The sense of losing oneself in a descent into frailty is likely to be most deeply felt. To acknowledge this, without glossing over it, belittling, or denying it, is helpful.
Even so, the sense of personhood, the feeling that one still matters, will be enhanced and supported if individual preferences and priorities are given consideration in this way.
It is also not a false or empty consolation, but absolutely true, that even when much is lost, disabled, and fragmented, each of us retains our individual character and spirit: we are who we are to the end. Especially in situations where dementia clouds the picture, where words and behaviours take startling and unexpected turns, chaplains and care staff have an important role in helping family members see that this is so. Family members in their turn provide essential links and information in helping care staff to build up an accurate understanding of each new resident’s background and personality.
Another important ingredient in the mixture of successfully making this big transition is humour. Not all clients are miserable, frightened, and grief-stricken; many accept this change in their circumstances with remarkable equanimity, and there are many clients who just love to have a laugh. They love banter and enjoy sharing a joke with the people who take care of them. Some people may even feel their dignity enhanced when someone makes a joke of a difficult circumstance rather than take it too seriously.
It is important to tread carefully here: nobody should be made the butt of humiliating mockery or have their problems and struggles belittled. Each person should be treated with consideration and respect. But relief from tension can be found in making light of a spilled drink, an incontinence accident, or many other trying and otherwise depressing daily challenges.
Points to remember